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The nurse is caring for a client with a history of atrial fibrillation who is receiving warfarin (Coumadin) 5 mg PO daily. Which of the following laboratory results should the nurse report immediately?
- A. INR of 3.5.
- B. PTT of 40 seconds.
- C. Platelet count of 200,000/mm^3.
- D. Hemoglobin of 13 g/dL.
Correct Answer: A
Rationale: An INR of 3.5 is above the therapeutic range (2.0–3.0), increasing bleeding risk. Options B, C, and D are normal.
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A client has been admitted for meningitis. In reviewing the laboratory analysis of cerebrospinal fluid (CSF), the nurse would expect to note
- A. High protein
- B. Clear color
- C. Elevated red blood cell count
- D. Increased glucose
Correct Answer: A
Rationale: High protein. A positive CSF for meningitis would include presence of protein, a positive blood culture, decreased glucose, cloudy color with an increased opening pressure, and an elevated white blood cell count.
A client with lung cancer is advised to increase the protein and kilocalorie content of his diet. Which of the following choices will best meet his need for increased protein and calories?
- A. Toast, jelly, chicken broth
- B. Crackers, butter, fresh vegetables
- C. Crackers, fresh fruit, ginger ale
- D. Crackers, cheese, fruit yogurt
Correct Answer: D
Rationale: Cheese and yogurt provide high protein and calories, ideal for a client with lung cancer needing nutritional support.
The physician suggests play therapy for a 7-year-old girl who is having some difficulty adjusting to her parents' impending divorce. The nurse knows this type of therapy is useful because
- A. young children have difficulty verbalizing emotions.
- B. children hesitate to confide in anyone but their parents.
- C. play is an enjoyable form of therapy for children.
- D. play therapy is helpful in preventing regression.
Correct Answer: A
Rationale: children have difficulty putting feelings into words; play is how they express themselves
A client with severe multiple trauma injuries from a motor vehicle accident.
After stabilizing a client with severe multiple trauma injuries from a motor vehicle accident, which of the following actions by the nurse is BEST?
- A. Limit visiting hours to promote optimal rest.
- B. Arrange for clergy to visit with the client and family as requested.
- C. Arrange for a psychologist to visit with the family.
- D. Arrange for the family to meet with a social worker to discuss financial aid.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? (1) inappropriate (2) correct-would provide the appropriate spiritual support necessary during a crisis (3) inappropriate for the data given in the situation (4) inappropriate for the data given in the situation
The physician prescribes sulfisoxazole (Gantrisin) 2 g PO qid for a client. Which of the following instructions is MOST important for the nurse to include when teaching the client about this medication?
- A. Drink plenty of fluids.
- B. Wear sunscreen when outdoors.
- C. Eliminate dairy products from your diet.
- D. Take this medication with meals.
Correct Answer: A
Rationale: Sulfisoxazole can cause crystalluria; adequate fluid intake prevents kidney stones. Options B, C, and D are less critical or incorrect.